Friday, April 2, 2010

Trickle Down Deception: Restaurants and the Pharmaceutical Industry

Yesterday I debated Steve DiFillippo, owner of Davio's and Avila's restaurants, on the WGBH program Greater Boston, hosted by Emily Rooney. The topic? The effect of the Massachusetts Gift Ban law on area restaurants.

On one level, it was a friendly debate on the economic impact of the law on those restaurants that depend on drug company sponsored dinners for a chunk of their income. You can watch the debate here. Please don't comment on my bad hair day.

But on another level, this is a larger and more worrisome issue, which is the trickle-down effect of deceptive marketing practices on the economy, such that very good people unwittingly help to perpetrate deceptive marketing practices.

When you do these news shows you arrive a half hour early and are greeted by the producer, who brings you to a waiting room where all the other guests are sweating it out in preparation for their five minutes of fame. For example, I got to meet House Speaker Robert DeLeo, who was there to talk up his proposal to legalize casino gambling in Massachusetts. I then had a pre-debate chat with Steve DiFillippo. He has created some amazing restaurants, one of which I have a personal connection with. My wife and I had our wedding rehearsal dinner at Davio's when it was in its former location on the Charles River in Cambridge.

Steve is a completely ethical person, does great community work, and was just given the Torch of Liberty award by the Anti Defamation League. Yet, here he was arguing that drug companies should be allowed to wine and dine doctors in order to sell them on their newest drugs. From his perspective, doctors, with all their training, should be smart enough to separate the hype from the truth. But unfortunately our extensive training does nothing to immunize us from the effects of marketing, as many companies have discovered. Merck, for example, found that hiring doctors to pitch other doctors at restaurants and other venues led to four times more Vioxx prescriptions. It didn't matter how much they spent on restaurants, they knew they would get a handsome return on their investment. Unfortunately, a bunch of people who took that Vioxx died of heart disease, and the drug was eventually taken off the market. As patients, we deserve to have our treatment decisions based on the medical literature, and not on the pitches of salesmen who have softened up their clients with cabernet and filet mignon.

I think if Steve and the other restaurateurs didn't have a dog in this race, they would agree with this. But they do have a dog in the race. And when your income stream depends on believing something, it's highly likely that you will believe it.

Steve, like thousands of other business owners, is a victim of "trickle-down deception." It begins with the drug companies, and spreads and expands where the money goes. Other victims include advertising companies, medical education communication companies, publishers, lunch caterers, celebrity spokespeople, etc.... In each of these industries, there are ethical people who believe they are just making an honest buck. But they are unwittingly participating in a system that depends on a basic deception: trying to dress up advertising in the guise of education.

The solution is to simply do what we are doing--keeping a close eye on the industry and reporting their most deceptive practices. Unfortunately, when they just can't behave themselves, we have to expend a lot time and effort to pass laws regulating them. The ensuing trickle down effect of honesty is something we can all support.

This has to be the most bizarre, surreal post to have ever occurred on your blog Dr Carlat. It is more befitting of an episode of the Twilight Zone or Seinfeld than anything else. What possible insights into the undo influence that pharmaceutical companies have on the prescribing habits of physicians could a restaurant owner have? They should have gotten the manufacturers of Geodon coffee mugs and maybe Zoloft clocks to team up on you along with this poor guy. Did the waitress's throw things at you on the way out of the studio? I feel bad for anyone's loss of business and understand their desperate attempts to stop the bleeding but it is again a wonderful example of how in almost every case people argue from a position of self interest even if they are convinced it is beneficent.

That's the concept of "an externality". "The effect of a transaction...on a thrid party who has not consented to or playde any role in the carrying out of that transaction" (Milton Friedman, economist). As a psychopathic creature, the Pharmaceutical Indutry can neither recognize nor act upon moral reasons to refrain from harming others. Nothing in its legal makeup limits what it can do to others in pursuit of its selfish ends, and it is compelled to cause harm when the benefits of doing so outweigh the costs.

I am really ill at ease with this post, but for different reasons, I think...Patience with me while I bring up a topic that is definitely related but will not seem immediately relevant.One of the most stunning analyses of the structure, intent, organization of propaganda can be found in Mein Kampf. Adolf Hitler was a master at propaganda, which is another etiquette for... you guessed it, advertising. If you manage to overcome your.. inhibitions and crack Mein Kampf, you will realize that if you substitute "advertising" for "propaganda", everything that Adolf says holds true. Look where Adolf got to with his propaganda...You should all know this already. I hope that you do, at least. So, we are talking about the diffusion of propaganda.But... our entire society is involved in spewing out propaganda 24 hours a day. Particularly the people involved in advertising. The propaganda has become so pervasive EVERYWHERE that it has significantly destroyed our faith in ourselves, and our institutions.And... you SERIOUSLY think that a few laws and regulations (how many of them do we already have ? are they doing the trick ??) are going to make a dent in this problem ?Unbelievable.

Debra,I completely agree that propaganda/marketing is everywhere, but this is not at all new. Perhaps we should be using More of it. Perhaps we should be doing all we can to "advertise" the things we believe helpful to our patients: activity/exercise/diet is important, finding/making social connections is a proven factor in recovery, family/friends participation in the recovery might be as helpful as meds, etc., etc. If our system made these things as palatable (socially and individually) and as convenient as meds, we might get a lot more "bang" for the "buck" of an appt. My PCP's waiting room is full of beautiful brochures from drug companies, but maybe it should be full of brochures about biking/hiking groups and knitting circles and book clubs and NAMI meetings and AA/NA meetings and even Hospice care (and all the wonderful things they can do for a patient & family BEFORE the last few weeks of life). Wait, maybe MY office should be full of these things, and have pt's complete a short (60 sec) questionnaire about exercise, food, social activities, drugs/alcohol before each visit so that we are prompted to talk about those things.

I'm not being sarcastic. Debra, you have inspired me. I can't stop the propaganda, but I can fight fire with fire. I don't have Madison Avenue's money or power, but I have propagandandist power better than "I'm not a doctor, but I play one on TV." For God's sake, I AM the doctor. I need to use that.

In the past, when things have gone badly wrong, Insider has subscribed to the idea that it's either due to a "cock-up" or a "conspiracy".

Now Paul Dieppe, from Bristol University has another possibility "complicity theory".

He relates this theory to the Vioxx/coxibs issue:

"Complicity works like this.

All those with a vested interest in an enterprise get sucked into the rhetoric associated with it, and they soon `believe' in everything that is going on within that enterprise. If personal financial gain is involved, corruption may also occur. So, in the case of drugs such as anti-inflammatory agents, researchers and prescribers work with the industry to promote the development, testing and use of these drugs.

Personal financial gains come through company shares, consultancies and free trips to exotic locations (for those who do research or actively promote the drugs), trips to educational meetings (for specialists), or `just' free lunches (for just about everybody—does any doctor still buy his/her own lunch?).11

If this goes on for long enough (and it has), everyone starts to believe that they are doing the right thing when they accept company largesse, and to believe in the drugs. And they do not realize that their ability to look at data critically, and at drug use objectively, has been compromised. So, when data comes along that says that rofecoxib causes heart attacks, lots of people say `wait a minute, rofecoxib is wonderful, so maybe the explanation for this is that the NSAID comparator (naproxen) is also a wonder drug and is protecting people against heart attacks'.12

The marketing pressures make all of this worse, of course. So when a paper gets published that says that celecoxib is wonderful, it gets distributed to everyone (as they attend the free lunch event). And when it turns out that the data are flawed (fraud?) the papers still go on being distributed to everyone.13

The pharmaceutical industry has developed a position of extraordinary power over governments, medical research and medical practice.14,15

But complicity theory makes it clear that this would not have been possible without others going along with their story. Doctors have been terrible in that regard; we now work in an industry where companies who stand to profit from our activities sponsor most of our postgraduate education.

Politicians are also to blame. For example, Gordon Brown is campaigning to keep the pharmaceutical industry in Britain, to help `UK plc', and one result of that is that all of us (including Medical Research Council scientists like myself), are being encouraged to work with the industry.

The complicity of politicians and health professionals with the pharmaceutical industry agenda, driven by the profit motive, has made us all blind to data and to common sense. For example, there is now widespread use of drugs (including NSAIDs and coxibs) for problems that are largely social, behavioural or mechanical in origin and the prevention and treatment of which is more logically approached through behavioural interventions than by the use of drugs.16

Most current medical research, as well as medical practice, is dominated by the vested interests of the multi-national pharmaceutical industry, which is now busy inventing diseases for which it can find drugs.17

We now live in a medical culture that appears to have become completely drug dependent—because of money.

Wow... reading this blog's comments is truly fascinating..Watching how the pendulum is swinging..It's not for nothing that I talk about the difficulty of maintaining both/and solutions in the face of the INCREDIBLE SOCIAL PRESSURE TO SWING THE PENDULUM TO THE "OPPOSITE" SOLUTION..Think about it for a minute.Not so long ago, really, the psychotropes came out, and the neuroleptics, and bingo, (most) everybody was saying... "hallelujah, we have just found a (new) God that is going to magically make everything right".And NOW... now that we are collectively discovering that... oops, everything is not going to be magically right, we start.. getting all disappointed, and angry, and pointing fingers, and saying.. "what a fraud", etc etc.Careful, not EVERYBODY is doing this.But, this kind of disappointment is getting a lot of attention in the big media.How about we listen a little LESS to big media, and concentrate on doing our jobs in our offices, WITH OUR PATIENTS ?We don't NEED to be more disappointed or disillusioned than we already are.We NEED to be asking ourselves tough questions about how we see our profession(s).But NOT kicking ourselves around the head for not being the IDOLS/IDEALS that we would LIKE to be, or that the medical bubble has set us up to be.Beware of anyone who wants to stick you on a pedestal. It's dangerous for your health. (And of course, that means... beware of YOU too, when you want to stick yourself on a pedestal...)

I read on the net recently that the Hippocratic oath is no longer taken by doctors. I think this is a interesting blog and that it is about time restaurateurs learned some of there money is made from a corrupt corporation that causes many a great deal of pain and suffering we can only hope they would bow out of this on their own. I am sure the bad press from supporting suck corrupt activities would not help their business any.

Don't let the restaurateur get away with the argument that drugs aren't a big cost--in Canada, drug costs surpassed physician pay for the first time in 1997, to become the second highest item (after hospitals) in our healthcare budgets. (You can find the info at http://www.hc-sc.gc.ca/hcs-sss/pharma/costs-couts/index-eng.php). Meeting surreality (as Dr John points out above) with evidence....

The bottom line is that there are multiple industries whetted to the blunting of branded medicine utilization (hmo's, pharmacy corporations, hospital corporations, large physician groups, pharmacy benefit managers). All of these industries reap large payments for generic utilization- complicity indeed. Call it a kickback if you want. There is a reason why the Obama administration targeted hmo's during healthcare reform.

It is very possible that new innovative medicines can reduce costs for the entire system. What is not possible, is that laws that hurt restaurants will decrease medicine cost.

I see hospital organizations and health insurance companies engaging in enterainment together frequently. I see hmo's at golf course events with physician leaders, as well as at expensive restaurants. What I do not see is big pharma or device companies engaging in these activities. Let's all observe the hypocrisy here. I hope this post makes it to the site, because if I am wrong, then I am sure someone will refute the post